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Peptic ulcer disease (PUD) is a chronic illness manifested by recurrent ulcerations in the stomach and duodenum. Acid and pepsin are crucial for ulcer development, but the great majority of ulcers are directly related to infection with Helicobacter pylori or nonsteroidal anti-inflammatory drug (NSAID) use. Gastritis is acute or chronic gastric mucosal inflammation and has various causes. Dyspepsia is upper abdominal discomfort with or without other symptoms that can have various causes or be functional.

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PUD typically presents with burning epigastric pain, though it may be described as sharp, dull, an ache, or an “empty” or “hungry” feeling. It may be relieved by the ingestion of food, milk or antacids, presumably due to an acid buffering or dilution effect. The pain recurs as the gastric contents empty and the recurrent pain classically awakens the patient at night. Atypical presentations are common in the elderly and may include no pain, pain that is not relieved by food, nausea, vomiting, anorexia, weight loss, and/or bleeding.

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A change in the character of the pain may herald the onset of a complication. Abrupt onset of severe pain is typical of perforation with spillage of gastric or duodenal contents into the peritoneal cavity. Back pain may represent pancreatitis from a posterior perforation. Nausea, vomiting, early satiety and weight loss may occur with gastric outlet obstruction or cancer. Vomiting blood or passing melanotic stools with or without hemodynamic instability represent a bleeding complication.

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PUD cannot be definitively diagnosed on clinical grounds, but it can be strongly suspected in the presence of a “classic” history (as above) accompanied by “benign” physical examination findings and normal vital signs with or without mild epigastric tenderness. Examination findings that may be indicative of PUD complications include: a rigid abdomen consistent with peritonitis in perforation; abdominal distension and succussion splash consistent with gastric outlet obstruction; occult or gross rectal blood or blood in nasogastric aspirate consistent with bleeding.

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The differential diagnosis of epigastric pain is extensive. Pain radiating into the chest, water brash, and belching may point to gastroesophageal reflux disease; more severe pain in the right upper quadrant (RUQ) radiating around the right side with tenderness suggests cholelithiasis or biliary colic; pain radiating into the back is common with pancreatitis and a concomitant mass may represent a pseudocyst or if the mass is pulsatile it could represent an abdominal aortic aneurysm. Chronic pain, anorexia, and weight loss with or without a mass may represent cancer. Myocardial ischemia may present as epigastric pain and should be strongly considered in the appropriate clinical setting.

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Some ancillary tests may be helpful to exclude PUD complications and to narrow the differential. A normal CBC rules out chronic (but not acute) bleeding. Elevated liver enzymes may indicate hepatitis and elevated lipase may indicate pancreatitis. An upright CXR may show the free air of a perforation and an abdominal US examination may show cholecystitis, cholelithiasis, or an abdominal ...

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